INTRODUCTION:Sarcoidosis is a multisystem disorder of unknown etiology. Some cases are attributed to genetic factors, an inflammatory response by specific antigens including self-antigen, and autoimmune involvement. Ninety percent of patients with sarcoidosis have lung involvement, and a vast portion is asymptomatic. Most common initial symptoms are dry cough and dyspnea, however, manifestation can be unspecific and broad. Ocular manifestations like uveitis are a classical presentation. Cutaneous manifestations have also been associated with sarcoidosis but incidence is around 1.9 per 100,000 with a female predominance. Diagnosis can be performed from clinical, and radiological findings yet one of the most essential criteria is histopathological findings of non-caseating granulomas on a tissue biopsy. Here is a rare presentation of a Hispanic male with sarcoidosis after exposure to an unusual antigen.CASE PRESENTATION: A 32-year-old man came to the emergency department with dyspnea, dry cough, and bilateral eye redness of one week of evolution and ten days after the second dose of the SARS-CoV-2 vaccine. Before these symptoms, the patient experienced multiple desquamating tattoos and bilateral eye redness after the first dose of the vaccine, which presumed that resolved with tobramycin and dexamethasone eye drops. Physical examination was notable for tattoo peeling with surrounding erythematous papules and tenderness to palpation. Eye examination revealed an intact visual acuity bilaterally with hyperemia and conjunctival injection. Ophthalmology made the diagnosis of non-granulomatous bilateral anterior uveitis. Routine laboratories were unremarkable including angiotensin-converting enzyme levels except for erythrocyte sedimentation rate on 32mm/Hr and arterial blood gas with a partial pressure of oxygen of 72 mmHg. Chest radiograph revealed innumerable bilateral centrilobular nodules. Chest Computerized tomography showed bilateral centrilobular diffuse pulmonary nodules with associated mediastinal paratracheal and mediastinal lymphadenopathy. Skin biopsy revealed a nodular infiltrate of histiocytes with black foreign body deposits with non-caseating sarcoid granulomas. Treatment consisted of prednisone and azathioprine resulting in an improvement of symptoms the following days. DISCUSSION:The side effects of this novel ribonucleic acid vaccine are not well described yet, but our case raises the suspicion if the vaccine arouses or unmask autoimmune diseases like the one previously described.CONCLUSIONS: More studies and data are required on side effects to assess other possible complications, response to the vaccine, and which patients are at risk of developing autoimmune or serious health conditions.

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INTRODUCTION: Pulmonary leukostasis (PL) is a medical emergency defined by an extremely high white blood cell count (WBC) with pulmonary symptoms with or without imaging findings. This condition is seen more frequently in acute myeloid leukemia or chronic myeloid leukemia during a blast crisis and confers up to 30% mortality. Symptoms usually do not occur unless WBC exceeds 400x10 ˇ 3 / mL in patients with chronic lymphocytic leukemia (CLL). Here we present an atypical presentation of this dreaded disease.CASE PRESENTATION: An 80-year-old man with a history of atrial fibrillation, benign prostatic hyperplasia, diabetes mellitus, and a recent diagnosis of chronic lymphocytic leukemia came to the emergency room with tachypnea, hypoxia, headache, slurred speech, drowsiness, and confusion. Days before his arrival, he began with bradyphrenia, subjective fever, and dry cough. Vital signs with tachypnea and peripheral oxygen saturation of 90%. Routine laboratories stood out for 95.2 x10 ˇ 3 / mL white blood cells, with 65% immature blood cells, 17% lymphocytes, 10% neutrophils, and arterial blood gas with metabolic alkalosis and hypoxemia. Supportive therapy began with respiratory therapies every four hours, aggressive intravenous hydration, and empirical antibiotics. Chest radiography and chest computed tomography failed to show effusions, infiltrates, or consolidations. Brain studies negative for intracranial pathology. Debulking and leukoreduction therapies were discussed with the patient who decided to continue with supportive therapy, even with the risk of tumor lysis. After observation and aggressive hydration, there was a significant clinical improvement that correlated with the decrease in WBC from 95.2x10 ˇ 3 / mL to 69.9x10 ˇ 3 / mL. Noteworthy, cultures and respiratory panel were negatives. The following days the antibiotics were suspended and the patient was discharged with scheduled chemotherapy. DISCUSSION: Leukostasis is an emergency condition that, if overlooked or misdiagnosed, could be fatal if left untreated. In case of clinical suspicion, expeditious treatment is indicated since the mortality rate is approximately 20 to 40 percent regardless of the leukocytosis.CONCLUSIONS: Although it is less common in CLL and almost unthinkable with WBC less than 100x10 ˇ 3 / mL; L This case highlights the important role of high clinical suspicion of PL even if not all medical criteria are met and its response to supportive and symptomatic therapy when implemented in a rapid timely manner.

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Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION:A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left panhemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA.CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes.